Bill
H 4346
The bill regulates PBMs and MAC lists to increase transparency, ensure fair pharmacy reimbursement, and protect patient access to medications.
Note on source material
- The available file appears to conflate two distinct items under the same docket number: (1) a Massachusetts House bill titled “An Act to ensure access to prescription medications” (text amending Mass. Gen. Laws ch. 176D to regulate pharmacy benefits managers), and (2) a South Carolina House resolution honoring Candice Herlong Pou on her retirement. This summary separates and highlights the substantive Massachusetts bill (the primary statutory text provided) and briefly notes the separate resolution and procedural entries.
Purpose
- Increase transparency and protect pharmacy reimbursement by regulating pharmacy benefit managers (PBMs) and covered entities’ use of maximum allowable cost (MAC) lists, with the stated goal of ensuring access to prescription medications and fair pharmacy payment.
Key provisions (selected)
- Definitions: “Maximum allowable cost list” (MAC list) and “maximum allowable cost” (MAC) defined as the maximum reimbursement by PBM/covered entity, inclusive of discounts, applied at claim processing or retroactively.
- Eligibility for inclusion on MAC list: A drug may be placed on a MAC list only if it is rated “A” or “AB” in FDA Orange Book (or NR/NA or similar national reference) and there are at least two therapeutically equivalent, multiple-source drugs, or at least one generic from a manufacturer, available from national/regional wholesalers.
- Removal: If a drug no longer meets eligibility, it must be removed from MAC list within 3 business days.
- Transparency: PBMs/covered entities must provide contracted/network pharmacies (and PS AOs for their network) with:
- sources used to set MACs;
- every MAC for drugs used for that pharmacy’s patients;
- MAC lists upon request; and make lists available in a secure, web-based or comparable format.
- Pricing and parity rules:
- MAC (or ingredient cost if MAC not used) must be ≥ pharmacy acquisition cost. Using NADAC (National Average Drug Acquisition Cost) as a floor is compliant.
- MACs for non‑affiliated pharmacies must be ≥ MACs for PBM‑affiliated/owned pharmacies.
- Update and processing timelines:
- PBMs must update each MAC list at least every 3 business days and make updates available to contracted pharmacies.
- Updated MACs must be used to calculate payments to contracted pharmacies within 2 business days.
- Appeals process:
- Pharmacies may contest a MAC within 7 business days of submitting the initial claim; PSAOs may appeal on behalf of pharmacies.
- PBM must resolve appeals within 7 business days of receipt.
- If appeal is denied, PBM must state reason and provide an NDC for an equivalent drug generally available at equal/lower price.
- If appeal is upheld, PBM must retroactively adjust the cost, reprocess impacted claims effective from appeal filing date, reimburse reprocessed claims, and adjust MACs for similar network pharmacies within 3 business days.
- Confidentiality: Pharmacies may not disclose MAC lists/related information to third parties, but may share with PSAOs or similar contracted administrative entities.
Who is affected
- Pharmacy benefit managers and covered entities administering pharmacy benefits.
- Retail, independent, and network pharmacies (including those served by PSAOs).
- Pharmacy services administrative organizations (PSAOs).
- Wholesalers supplying drugs.
- Indirectly affects patients via pharmacy payment policies that can influence drug availability and dispensing.
Procedural / timeline notes (MA bill)
- Origin: Committee on Financial Services reported favorably (file references a petition/H.1326).
- Reported from committee: 2025-07-31.
- Referred to Committee on Health Care Financing (reported favorably same day per file).
- Several entries show “scrivener’s error corrected” on 2025-04-24 and 2025-05-28 (see note below).
Compiled from official sources — confirm details with the bill’s official record.
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